ABSTRACT Minimum Inhibitory Concentrations (MICs) are the gold standard for quantitatively measuring antibiotic resistance. However, lab-based MIC determination can be time-consuming and suffers from low reproducibility, and interpretation as sensitive or resistant relies on guidelines which change over time. Genome sequencing and machine learning promise to allow in-silico MIC prediction as an alternative approach which overcomes some of these difficulties, albeit the interpretation of MIC is still needed. Nevertheless, precisely how we should handle MIC data when dealing with predictive models remains unclear, since they are measured semi-quantitatively, with varying resolution, and are typically also left- and right-censored within varying ranges. We therefore investigated genome-based prediction of MICs in the pathogen Klebsiella pneumoniae using 4367 genomes with both simulated semi-quantitative traits and real MICs. As we were focused on clinical interpretation, we used interpretable rather than black-box machine learning models, namely, Elastic Net, Random Forests, and linear mixed models. Simulated traits were generated accounting for oligogenic, polygenic, and homoplastic genetic effects with different levels of heritability. Then we assessed how model prediction accuracy was affected when MICs were framed as regression and classification. Our results showed that treating the MICs differently depending on the number of concentration levels of antibiotic available was the most promising learning strategy. Specifically, to optimise both prediction accuracy and inference of the correct causal variants, we recommend considering the MICs as continuous and framing the learning problem as a regression when the number of observed antibiotic concentration levels is large, whereas with a smaller number of concentration levels they should be treated as a categorical variable and the learning problem should be framed as a classification. Our findings also underline how predictive models can be improved when prior biological knowledge is taken into account, due to the varying genetic architecture of each antibiotic resistance trait. Finally, we emphasise that incrementing the population database is pivotal for the future clinical implementation of these models to support routine machine-learning based diagnostics. Data Summary The scripts used to run and fit the models can be found at https://github.com/gbatbiff/Kpneu_MIC_prediction . The Illumina sequences from Thorpe et al. are available from the European Nucleotide Archive under accession PRJEB27342 . All the other genomes are available on https://www.bv-brc.org/ database. Impact statement Klebsiella pneumoniae is a leading cause of hospital and community acquired infections worldwide, highly contributing to the global burden of antimicrobial resistance (AMR). Ordinary methods to assess antibiotic resistance are not always satisfactory, and may not be effective in terms of costs and delays, so robust methods able to accurately predict AMR are increasingly needed. Genome-based prediction of minimum inhibitory concentrations (MICs) through machine learning methods is a promising tool to assist clinical diagnosis, also offsetting phenotypic MIC discordance between the different culture-based assays. However, benchmarking predictive models against phenotypic data is problematic due to inconsistencies in the way these data are generated and how they should be handled remains unclear. In this work, we focused on genome-based prediction of MIC and evaluated the performance of interpretable machine learning models across different genetic architectures and data encodings. Our workflow highlighted how MICs need to be treated as different types of data depending on the method used to measure them, in particular considering each antibiotic separately. Our findings shed further light on the factors affecting model performance, paving the way to future improvements of antibiotic resistance prediction.
